Stockist Application

Please fill out the following form in as much detail as possible so that we can process your Tri-Vortex application as soon as possible.

After we have reviewed your application, we will forward stockist information to you.

Your Name & Address

Title *

First Name *

Last Name *

Your Email Address *

Website Address *
(You must have a website)

Company Name

ABN (Australian Business No.)
(Australian Stockists Only)

Street Address 1 *

Street Address 2

Town *

State *

Post Code / Zip Code *

Country *

Live in Singapore or South Africa? Please contact our affiliate offices.

Your Contact Numbers

Note: Please include your country and area code in front of your home phone number. (If you know them) No other characters, just numbers please.

Phone Number Type*

Phone Number *

Other Phone Number Type

Other Phone Number

Fax Number Type

Fax Number

Your Marketing Information

Which applies to you? *

If a Health Practitioner, what is
your field of work?

If 'Other' please specify

How did you find out about Tri-Vortex? *

If 'Other' or 'Word of Mouth' please specify

Please tell us... *
- About your business?
- How will you promote Tri-Vortex?
- About your contacts - How you contact them and how often?

Login & Commission Payment Information

Create Your Affiliate Code *

Your code must start with a letter. Your code will be shown in your affiliate (web/email) link.
Eg. https://dm01.infusionsoft.com/go/home/YourCode

Your Affiliate Login Password *

Retype Login Password *

Bank Details (Australia Only)

Bank Name

Bank BSB (123-456)

Bank Account Name

Bank Account Number

Paypal Email
(Outside Australia Only)

Get a free Paypal account here

I agree with the terms of service

* Mandatory information

Providing this information constitutes your permission for Universal Source P/L (Tri-Vortex) to contact you regarding related information via mail, email, fax and phone. Please note: We will NEVER sell, rent, exchange, trade or disclose your details to any company or individual.